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[Editorial] Medical negligence: there are no winners

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Medical negligence costs in the UK National Health Service (NHS) are reaching new unsustainable heights. Earlier this month, a 9-year-old girl was awarded a settlement that could amount to over £19 million (US$25 million) after she was born with severe jaundice, resulting in brain injury. The NHS spent £1·8 billion on negligence claims in the 2017–18 financial year and the annual cost has doubled since 2010. Estimated total liabilities for 2017–18—the cost facing the NHS if all claims against it were successful—is £65·1 billion, up from the 2015–16 estimate of £56·4 billion.

[Editorial] Health care in conflict: war still has rules

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Denouncing attacks on health-care facilities and personnel in conflict situations, the UN Security Council unanimously adopted resolution 2286 in May, 2016. Addressing the Council, then UN Secretary-General Ban Ki-moon, condemned military actions leading to destruction of health-care facilities as war crimes, and called on Member States to honour their obligations to protect health-care workers and patients in conflict saying “even war has rules”.

[Editorial] Essential diagnostics: a lever for health systems reform?

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Last week, WHO released its first Essential Diagnostics List. Designed to complement the Essential Medicines list first released over 40 years ago, the list defines an essential package of diagnostic tests for use in primary care and laboratory settings. 58 of these tests are aimed at supporting the diagnosis and monitoring of common conditions such as cardiovascular diseases, diabetes, and anaemia, and 55 tests are targeted at high priority diseases including HIV, hepatitis B and C, and malaria.

[Comment] Shingles vaccine after auto-HSCT decreases risk

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Infection is a major cause of morbidity and mortality after autologous haemopoietic stem-cell transplantation (auto-HSCT). Worldwide, most adults have latent varicella zoster virus and so are at risk of viral reactivation, causing herpes zoster (ie, shingles). Reactivation can occur after myeloablative conditioning and subsequent auto-HSCT because of impaired varicella zoster virus-specific T-cell immunity. Despite the known reduction in the risk of herpes zoster after auto-HSCT by use of prophylactic antiviral therapy (with aciclovir or valaciclovir), guidance on the duration of and adherence to therapy is variable.

[Comment] Pervasive genetic testing

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On March 6, 2018, the US Food and Drug Administration (FDA) authorised the DNA testing company 23andMe's Personal Genome Service that offers mail-order testing for selected variants of the BRCA1 and BRCA2 breast cancer genes.1 This service analyses DNA from a self-collected sample of saliva, and results are available through an online portal. The subsequent report may determine whether an individual is at an increased risk of developing several cancers linked to these gene mutations, including breast, ovarian, fallopian tube, peritoneal, prostate, and pancreatic cancer.

[Comment] Offline: “The world has been warned”

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What is the extent of the obligation health professionals have to the society in which they live? Beyond immediate patient care, a health worker will be an advocate for a properly financed and functioning health system. But what about the broader political context of health? To support publicly provided health services, governments must generate revenue. Adequate financing for health demands economic growth to create the fiscal space for investment. A health professional might reasonably have an interest in policies that ensure sustainable economic growth—for without that growth, health services will fall into disrepair and the quality of care will inexorably decline.

[World Report] Health for migrants and Dominicans of Haitian descent

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Hundreds of thousands of people whose official status is bogged down in administrative struggle are afraid to access health care in the Dominican Republic. Amanda Sperber reports from Palmarejo.

[World Report] Canada reveals needle exchange programme in prisons

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Following pressure from activists, the Canadian Government announced two federal prisons will offer a needle exchange programme before a national roll-out. Paul Webster reports from Toronto.

[World Report] Ebola outbreak in the DR Congo: lessons learned

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Experts are cautiously advising against declaring an international emergency, while rapid response is thought will help contain the spread of the outbreak. Andrew Green reports.

[Perspectives] Improvising medicine

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For many clinicians, the word improvisation has a pejorative whiff—it smacks of being lazy, unprepared, or unprofessional. But improvisation is essential to clinical practice and we should prize, embrace, and practise it.

[Perspectives] Life itself

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Tate Britain's exhibition All Too Human: Bacon, Freud, and a Century of Painting Life aims to capture “the sensuous, immediate and intense experience of life in paint”: an ambitious statement of intent that could easily apply to the contents of most galleries. In practice, the indoor, daylight-shy world of Francis Bacon and Lucian Freud's work—and personalities—predominates. Walter Sickert's fin-de-siècle bedroom nudes anticipate the sometimes seamy urban underworld they inhabited. John Deakin's cramped photographs document London characters such as Bacon's doomed lover George Dyer, captured here in anxious profile.

[Perspectives] Catherine Karr: improving paediatric respiratory health

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Catherine Karr, Professor of Pediatrics and Environmental and Occupational Health Sciences at the University of Washington (UW) in Seattle, WA, USA, aims to improve child respiratory health, including among remote communities in Washington state. As a paediatric environmental medicine specialist and environmental epidemiologist, her work has centred on the environmental disparities that impact on child health. “Exposure to environmental pollutants, indoor or outdoor, can really affect children's health”, says Karr.

[Perspectives] Neglected encounters: addiction and the meaning of pain

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In the winter of my intern year, I would arrive at hospital in the darkness of early morning. Walking from room to room down the quiet hall, I watched the sun first glowing at the horizon, then rising above the Boston skyline by the time I checked in with all of my patients. Some patients awoke when I knocked on the door; others had to be shaken lightly. Plenty had been up all night. Occasionally, I just watched in silence from the doorway to see that they were breathing, knowing we would soon be back for rounds.

[Obituary] Mathilde Krim

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Immunologist and prominent AIDS activist. Born on July 9, 1926, in Como, Italy, she died on Jan 18, 2018, in Kings Point, NY, USA, aged 91 years.

[Correspondence] Rapid response to HPV vaccination crisis in Ireland

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The human papillomavirus (HPV) vaccination school-based programme for girls aged 12–13 years began in Ireland in 2010. Initially, the proportion of students who completed the vaccination course was above 80%, increasing to a high of 86·9% in 2014–15 (figure). No variance was seen between schools of different religious ethos, although disadvantaged schools had a lower mean uptake than other schools in 2013–14 (79·4% vs 85·0%; difference 5·58%, 95% CI 2·69–8·21).2 However, the proportion of girls who completed the vaccination schedule in 2015–16 dropped to 72·3%, and uptake of the first dose decreased further across all areas to an estimated 50% in 2016–17.

[Correspondence] Daytime variations in perioperative myocardial injury

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With great interest, we read the Article by David Montaigne and colleagues (Jan 6, p 59)1 on daytime variations of perioperative myocardial injury. Data from our group regarding the circadian influence on myocardial ischaemia fully support the findings that decreased cardiac Rev-Erbα signalling is cardioprotective in the afternoon.2 However, we found it quite puzzling that in this publication the circadian expression levels in human beings are in opposition to those found in mice, and that the Per2 gene is in phase with the Rev-Erbα gene.

[Correspondence] Daytime variations in perioperative myocardial injury

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We read with interest the Article by David Montaigne and colleagues1 reporting that among patients having on-pump cardiac surgery for aortic valve replacement, the time of day that surgery is done might affect their tolerance to ischaemia–reperfusion injury. The results are intriguing and we commend the researchers for their comprehensive translational study.

[Correspondence] Daytime variations in perioperative myocardial injury

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We read the Article by David Montaigne and colleagues1 with interest and congratulate them for their impressive study. The study investigated whether Rev-Erbα-induced circadian variation of ischaemia–reperfusion tolerance exists. This investigation was done by taking atrial trabeculae samples from patients who had undergone aortic valve replacement, operated on in the morning or afternoon, before cardiopulmonary bypass. The samples were then exposed to in-vitro ischaemia–reperfusion injury. Additionally, a Langendorff model, using the hearts of Rev-Erbα knockout mice that were exposed to either ischaemia–reperfusion alone or after treatment with a Rev-Erbα antagonist, showed that the hearts were rescued from the inhibitory effect of Rev-Erbα on cardioprotective transcription factors and were therefore able to regain ischaemia–reperfusion tolerance.

[Correspondence] Daytime variations in perioperative myocardial injury – Authors' reply

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We thank the correspondents for their interest in our Article.1 Bartman and colleagues found the circadian gene expression results in our study puzzling. Although the mouse is a nocturnal species, the pattern of circadian gene expression is the same when comparing the sleep-to-wake and wake-to-sleep transitions. To the best of our knowledge, both in human and rodent tissues, Rev-Erbα gene expression was found in phase with Per2 and anti-phase to Bmal1, with high expression of Rev-Erbα at the sleep-to-wake transition.

[Articles] Inactivated varicella zoster vaccine in autologous haemopoietic stem-cell transplant recipients: an international, multicentre, randomised, double-blind, placebo-controlled trial

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This study shows for the first time in a large phase 3 trial that early vaccination of auto-HSCT recipients during the peri-transplant period can be effective for the prevention of an opportunistic infection like herpes zoster and that the vaccine is well tolerated.